A healthcare provider, such as a pharmacy, pharmacist, doctor's office, urgent care center, physician, hospital, or the like provides numerous healthcare related products and services to patients, including providing prescription products (e.g., medications, devices, etc.) or services to a patient. Typically, a healthcare claim transaction, such as a prescription claim transaction, prescription billing request, or medical claim transaction, is generated by the healthcare provider and sent, either directly or indirectly, to a claims processor (e.g., a pharmacy claims processor) for adjudication. In some cases, the healthcare claim transaction is sent to a claims processor (e.g., a pharmacy claims processor) by way of an intermediary such as a service provider or switch. The healthcare claim transaction typically includes information that identifies the patient, the prescribed product (e.g., medications, devices, etc.) or service being requested, the healthcare provider (either the prescriber, pharmacy, or both), and the benefit plan, insurer, or government-funded payor for the patient.
Prescription discount cards can be provided to patients to aid in procuring a medication, product, or service at a lower out-of-pocket price. There are two primary scenarios in which a prescription discount card is used: (i) “Cash” customers seeking a lower medication price than the standard Usual and Customary Charge for a cash transaction at a pharmacy; and (ii) “Pharmacy benefit” patients (e.g., patients having healthcare insurance coverage for prescription medications) that are seeking a lower price for the desired or prescribed medication, product, or service than the standard Usual and Customary Charge offered by the pharmacy for a cash transaction when the particular medication, product, or service isn't covered (reimbursable) by the patient's insurance provider. The issuer of the discount cards makes money when the card is used.
Pharmacies must balance the opportunity to dispense a prescribed medication, product, or service to a patient against the costs of providing the medication, product, or service. The opportunity cost consideration is specifically difficult for patients using a cash discount card to obtain their prescriptions when the “cash” prescription price (e.g, the patient purchase price or patient pay amount) is equal to the standard Usual and Customary Charge offered by the pharmacy for a cash transaction or less than the standard Usual and Customary Charge amount offered by the pharmacy for a cash transaction plus the card processing fee. In these situations, providing the prescribed medication, product, or service under the reduced discount card based price can result in reduced profits or even a loss for the pharmacy.